USA WELLNESS VERIFICATION

THIS ONLINE FORM MUST BE SUBMITTED BEFORE 4:00 PM
THE DAY BEFORE RETURNING TO CLASS!

Otherwise, parents must sign a form at the school prior to the child entering the classroom.

Parents are responsible for ensuring that their child is healthy before sending him/her to class. The following checklist should be followed in monitoring your child. This form must be verified and signed prior to sending your child back to school after an illness or absence that does not involve COVID symptoms. If symptoms are present, your child should be seen by a doctor and only return to school with a doctor’s note indicating that he/she may return.

I verify that my child has been free of any of the following symptoms for at least 24 hours prior to returning to school.

• Fever or chills • Shortness of breath or difficulty breathing • Unusual muscle or body aches • Cough • Sore throat • Nausea or vomiting • Diarrhea • Congestion or runny nose not due to allergies • Headache

YES

I verify that my child has not been in contact with anyone diagnosed with COVID-19 nor has been notified that he/she may have been exposed to it.

If exposed your child must remain at home for two weeks before returning to school, and be free of symptoms.

YES

I verify that my child has not traveled out of the area (anywhere farther than adjoining counties), and has kept separated from others not in the household as much as possible.

If traveling out of the area, the child must be quarantined for two weeks prior to a return to school, and free of any symptoms.

YES

Name of Parent/Guardian:

First Name

Last Name

Child(ren)'s Name(s):

(Children who were absent)

Date Absent:

YYYY

Date Returned:

YYYY

Confirm Info

By submitting this form I attest to this information being accurate and complete and that I am the legal guardian of this child.

USA WELLNESS VERIFICATION

Uncharted Shores Academy

330 E Street, Crescent City, CA 95531 • Office@ShoresAcademy.com
(707) 464-9828 • FAX (707) 464-1428